1. Transformation Changing the MR System to Make Every Day Lives a Reality December 03, 2001 Dennis W. Felty

2. ASSUMPTIONS 4 This is a time of great opportunity for individuals and their families 4 This is a best effort to describe a rapidly changing system 4 Much of what we talk about may change 4 This is the biggest change ever

3. AN EVERY DAY LIFE a person's basic needs, to reaching a rich quality of life in all aspects of a person's life. It is always changing throughout a person's entire life experience. It is the kind of life we all want and is not unique to people who happen to have disabilities. An every day life is a life rich in the qualities a person most desires; one that shows how connected we are to each other. It is a life that grows from a person's own choices, desires and dreams and is not controlled by what kind of services happen to be currently available. It goes beyond just meeting

4. TRENDS 4 Waiver entitlement (Olmstead letter #4) 4 Olmstead/ADA entitlement 4 Federalization of MR funding & policy 4 CMS requirement for equitability 4 CMS requirement for consistency 4 Choice, Individualized Funding and Self Determination 4 Data requirements for legislative initiatives & full funding 4 OMR & DPW Information Technology initiatives 4 Baby boomer demographics & waiting list 4 $1,600,000,000 provided for services in Pennsylvania

5. POLICY OPTIONS u State fee schedule (EPSTD, partial, outpatient) u Managed care model with MCO (Health Choices) u Limited access & utilization (commercial behavioral health) u Withdraw from Medicaid u Continue with current system u Comprehensive resource management system

7. OLMSTEAD LETTER #4 42 CFR 441.303(f)(6) “The State must indicate the number of unduplicated beneficiaries to which it intends to provide waiver services in each year of its program.This number will constitute a limit on the size of the waiver program unless the State requests and the Secretary approves a greater number of waiver participants in a waiver amendment. Thus, unlike Medicaid State plan services, the waiver provides an assurance of service only within the limits on the size of the program established by the State and approved by the Secretary. The State does not have an obligation under Medicaid law to serve more people in the HCBS waiver than the number requested by the State and approved by the Secretary. If other laws (e.g.,ADA) require the State to serve more people,the State may do so using non-Medicaid funds or may request an increase in the number of people permitted under the HCBS waiver. Whether the State chooses to avail itself of possible Federal funding is a matter of the State ’s discretion.Failure to seek or secure Federal Medicaid funding does not generally relieve the State of an obligation that might be derived from other legislative sources, such as the ADA.”

8. OLMSTEAD LETTER #4 “A State is obliged to provide all people enrolled in the waiver with the opportunity for access to all needed services covered by the waiver and the Medicaid State plan. Thus, the State cannot develop separate and distinct service packages for waiver population subgroups within a single waiver. The opportunity for access pertains to all services available under the waiver that an enrollee is determined to need on the basis of an assessment and a written plan of care/support. This does not mean that all waiver participants are entitled to receive all services that theoretically could be available under the waiver. The State may impose reasonable and appropriate limits on utilization.”

9. OLMSTEAD LETTER #4 “Once in the waiver, an enrolled individual enjoys protection against arbitrary acts or inappropriate restrictions, and the State assumes an obligation to assure the individual’s health and welfare.” page 6, paragraph 3

10. OLMSTEAD LETTER #4 “We appreciate that a State’s ability to provide timely access to particular services within the waiver may be constrained by supply of providers, or similar factors. Therefore, the promptness with which a State must provide a needed and covered waiver service must be governed by a test of reasonableness. The urgency of an individual’s need, the health and welfare concerns of the individual, the nature of the services required, the potential need to increase the supply of providers, the availability of similar or alternative services and similar variables merit consideration in such a test of reasonableness.” page 6, paragraph 4

11. OLMSTEAD LETTER #4 “The fact that states have the authority to limit the total number of people who may enroll in a waiver provides states with reasonable methods to control the overall spending. This means that states should be able to manage their waiver budgets without undermining the waiver purpose or quality by exceptional restrictions applied to services that will be available within the waiver.” page7, paragraph 5

13. MEDICAID WAIVERS u Person/Family Driven Supports Waiver (PFDS) u Non entitlement re having all needs met u IER u $21,125 maximum funding u Implemented as pilot in July 2002 then state wide in Jan 2003 u Home and Community Based Services Waiver (HCBS) u Entitled to have all needs met u IER u No cap on maximum funding u Includes residential services

14. PFDS PILOT COUNTIES July 1, 2002 u Dauphin u Delaware u Westmoreland u Berks Other counties my choose to begin implementation July 1, 2002

15. TIME LINE u PFDS PilotJuly 2002 u PFDS StatewideJan 2003 u ITQJan 2003 u HCBSJuly 2003 u MAMISNov 2003?

16. PFDS WAIVER SERVICES u Day service (licensed 2380 and unlicensed) u Pre - Employment and Supportive Employment u Community Habilitation u Physical Therapy u Occupational Therapy u Visiting Nurses u Behavior Therapy u Visual Mobility Therapy u Transportation u Speech and Language Therapy u Respite u Personal Support for Community Integration u Vendor

17. SERVICE DESCRIPTIONS “Services Descriptions” define the services that are available under the PFDS Waiver. People enrolled in the Waiver can only receive services described and approved in the Waiver. Similarly, providers can only bill for service activities described in the service descriptions of the Waiver. The provider will be responsible to assure that all services billed meet the specifications of the service descriptions.

18. SYSTEM ELEMENTS u Choice & Self Determination u Entitlement & equity driven u Geographic choice u Individual Service Plan (ISP) u Individual Estimated Resources (IER) Target Budget u Individualized funding u Invitation to Qualify (ITQ) u Prospective Fee based u State wide waivers with consistent benefits u Comprehensive web based data system

19. Waiver 1000 enrollees $20,000,000 Provider County Contingency Fund $400,000 Emergency Services & Waiting List Funding 100/year $2,000,000 To meet increased needs of people enrolled in the waiver ISP 1001 $100,000 WAIVER FUNDING

20. HCBS Waiver 1000 enrollees $20,000,000 County Contingency Fund $400,000 Emergency Services & Waiting List Funding 100/year $2,000,000 To meet increased needs of people enrolled in the waiver ISP 1001 $100,000 ISP 1 + ISP 2 + ISP 3 …. ISP 1000 = $20,000,000 ISP 1 + ISP 2 + ISP 3 …. ISP 1001 = $20,100,000 ISP 1 + ISP 2 + ISP 3a ….ISP 1000 = $20,000,000 ISP 1 + ISP 2 + ISP 3 …..ISP 1100 = $22,000,000 ISP 1 + ISP 2 + ISP 3 …. ISP 999 = $20,000,000 ISP 1 + ISP 2 + ISP 3 …. ISP 1000 = County Allocation COUNTY CONTINGENCY FUND

21. County Contingency Fund $400,000 To meet increased needs of people enrolled in the waiver Year 1 - ISP 1 + ISP 2 + ISP 3 …. ISP 1000 = $20,000,000 Year 2 - ISP 1 + ISP 2 + ISP 3 …. ISP 1000 = $20,800,000 COUNTY CONTINGENCY FUND HCBS Waiver 1000 enrollees $20,000,000

22. ISP/PAYMENT PROCESS 2003 Need Assessment IER Target Budget Individual Service Plan Selection of Provider MAMIS Fee Schedule Service Contract Service Encounter Invoice MAMIS Claims Payment Payment Authorization to County County pays Invoice County Approves Rate ITQ Invitation to Qualify Rate Negotiation & Contract OMR Allocation

23. HCSIS DATA SYSTEM Home & Community Services Information System u State wide u Web based u Invitation to Qualify u Incident Management u Needs assessment data u Individual’s Estimated Resources (IER) u Individual Service Plan (ISP) u Individualized budget u Claims payment (MAMIS) u Provider performance data u Longitudinal u Statistical analysis of needs assessment & cost

24. MCO Provider OMR/County Consumer Family Provider SYSTEM STRUCTURE Consumer Family Consumer Family Consumer Family ISO

25. FEE OPTIONS u County set fee u Provider County negotiated fee u Vendor fees

26. PFDS RATE SETTING The provider will propose a rate for each service in each county they designate in their ITQ declaration. Each rate proposal will be negotiated by each county and the provider. When the county and provider reach agreement, the county will issue a contract on the rate and when the contract is signed the rate will be entered into the HCSIS county fee schedule. The provider may propose different rates for the same service provided in different locations. The 4300 fiscal regulations will not apply to PFDS Waiver services, however the provider will disclosure profits by contracted rate in their audit.

27. PFDS RATE SETTING COMPONENTS u Rates will be prospective. u There will be no cost settlement. u The 4300 regulations will not apply to PFDS services. u Rates will be effective on the date they are approved by the county and are entered into the HCSIS Fee Schedule. u Rates may not be applied retroactively. u With the agreement of the county and the provider, rates may be changed mid year. u OMR may publish guidelines on rate setting and appropriate cost components of proposed rates. u Providers may be required to report profit levels in their audit. Such information may by used in subsequent rate setting. u There may be multiple rates for different provider sites.

28. RATE SETTING COMPONENTS u Cost per hour of work u Hours available that are scheduled u Travel time per visit u Phone time per visit u Case coordination per visit u Cost of marketing u Cost of capital u Service Descriptions u HIPAA compliance costs u Cost of compliance u No shows u Administration u Training u Rejected invoices u Profit/retention u Cost of infrastructure u Direct travel cost per visit u Incident management u Unit rounding A rate setting model is available at: http://www.keystonehumanservices.org/links.html#rate

29. THE IMPORTANCE OF A CAPITAL BASE u Working capital u A more dynamic commercial market u Choice u Compliance risk u Increased loss exposure u Infrastructure investment u Business development

30. DOWNSIDE LOSS EXPOSURE u Choice u Unfunded ISP Components u High transaction costs u Infrastructure costs u Utilization loss u Marketing costs u Compliance & audit risk u Rates u No retroactive contract adjustments u Claims payment loss u Cost of capital u Start up & business development

31. CLAIMS PAYMENT MAMIS, the state Medicaid Claims Payment system will be utilized. Providers will submit invoices for each encounter (hour, 1/4 hour or day of service). MAMIS will validate the invoice against: the ISP, the IER, the individualized budget (frequency) and the county fee schedule. If all screens pass, MAMIS will authorize the county to make payment. Note: The MAMIS system will not be available until 2003.

32. CLAIMS PAYMENT Prior to MAMIS being available for claims payment processing, providers will submit invoices to the county.

33. SERVICE AUTHORIZATIONS When the ISP is completed and is within the IER, the county will authorize the services. The provider may continue to provide the services and bill for services as long as the county service authorization is in effect.

34. MAMIS - CLAIMS PAYMENT MAMIS, the state Medicaid Claims Payment system will be utilized in 2003. Providers will submit invoices for each encounter (hour, 1/4 hour or day of service). MAMIS will validate the invoice against: the ISP, the IER, the individualized budget (frequency) and the county fee schedule. If all screens pass, MAMIS will authorize the county to make payment. Note: The MAMIS system will not be available until 2003.

35. COMPLIANCE In a Medicaid fee for service environment, a provider has a very significant responsibility to assure that invoices submitted are valid and that all services billed were fully delivered. Incorrect invoices, regardless of intent, may be defined as Medicaid fraud with very serious penalties including criminal liability for both individuals and corporations. Providers may want to give very serious consideration to establishing a Corporate Compliance Program.

36. COMPLIANCE In a Medicaid fee for service, anyone, who has knowledge of incorrect bills has an obligation to disclose that information to the office of Medical Assistance. Consistent with direction from the Office of Medical Assistance the provider may be required to do a self audit (outside independent auditors) to review all bills for the defined period. The provider may be required to make restitution plus penalties for all incorrect payments. The Office of Medical Assistance provides for an informant to be eligible for a cash reward of up to 25% of the recovered funds.

37. HIPAA COMPLIANCE Under the Health Insurance Portability and Accountability Act - provider agencies are responsible for full compliance with HIPAA regulations relevant to the confidentiality and safe keeping of health care information under Transformation and HICSIS.

38. “The doctor’s lawyer will see you now.” New Yorker Book of Doctor Cartoons

39. Rigorous compliance environments, within systems that require increasing precision, risk compliance and infrastructure costs that will not be cost effective and may have an adverse effect on viability.

40. INDIVIDUALIZED SERVICE PLAN The team, comprised of the individual, family, friends and other persons who care about the individual, will develop an ISP (Individual Service Plan). The ISP is designed to meet the person’s needs, service and support preferences. The ISP will be developed within the context of an individual Estimated Resource budget (IER). The IER is a threshold number that sets an estimate of resources available to the individual.

41. PERSONAL SUPPORTS BROKER One of the exciting services available is a Personal Supports Coordinator. This option would permit an individual or their family to select a consultant or advocate to support and/or participate in the ISP and provider selection process. This person could assist in planning, advocacy, identifying natural supports, preferences, service model options, costs, innovative alternatives, evaluating and selecting providers. The cost of this service can be funded through the person's ISP.

42. INVITATION TO QUALIFY In order to maximize choice and competition, an ITQ (Invitation To Qualify) process will be used where all provider agencies that meet state qualifications will be entitled to be on the County’s approved provider list. After completing the ISP, an individual or family may then select any provider or combination of providers on the list to carry out the ISP. Providers will then be reimbursed at their approved rate for the contracted service. Families will have the option of using existing providers, starting a new provider agency, or use of informal supports including friends, family and neighbors.

43. “I’m sorry. The doctor no longer makes phone calls.” New Yorker Book of Doctor Cartoons

44. INVITATION TO QUALIFY u Single qualification at state level u Provider determines which county(s) they want to provide services in u Provider determines which services they will provide in each county u Provider submits rate proposal for each service in each county u Provider county(s) negotiate a rate for each service u the rate is entered into county HCSIS rate schedule u ISP costs are developed against provider rate schedule u Provider agrees to provide service

45. GEOGRAPHIC CHOICE The Waivers are state wide waivers and, as such, a family or consumer has the right to receive services to which they are entitled anywhere in the state. If a family wants to receive services in an adjoining county, they may do so. The provider they select will have to be placed on their home county ITQ list and the provider will be paid by the family’s home county at the rate approved in the county where the services are delivered.

46. CHOICE Choice is a foundation principle in Transformation. It provides the person using services and their family with greater control over resources and the selection of the people and providers that will be providing their supports. Choice operates within the parameters of the ISP, the IER, ITQ, service descriptions and providers’ willingness and ability to provide services. The ISP is the central document that ultimately defines decisions around Choice and provides the formal authorization for services to be funded by the county.

47. CHOICE ISSUES u Who speaks for the person being served u CMS requirement that a person’s needs be met u Competency and informed consent u The individuals Needs Assessment u Individual Service Plan (ISP) u Individual Estimated Resources (IER) u # of Providers on Invitation to Qualify List (ITQ) u Provider and county capacity u Waiver Service Descriptions u Enrollment in PFDS or HCBS Waiver u Number of providers willing and able to provide services u County authorization for services

48. CHOICE & SYSTEM CAPACITY An essential element of Choice is that there are several, perhaps three or more providers willing and able to provide the services described in the ISP.

49. INTERMEDIARY SERVICE ORGANIZATION Each county will have an Intermediary Service Organization or ISO. The role of the ISO is to serve as an agent that will pay bills for services that are not offered by provider agencies through the County ITQ process. These include services that tend to be informal and offered on an hourly basis. The ISO may also serve as the employer for these persons and can also arrange for the purchase of adaptive equipment and accessibility modifications.

50. SERVICE COORDINATOR The Service Coordinator will have extensive influence on the ISP process including the integrity of the process and family and consumer satisfaction and confidence. They will carry significant responsibility for presenting options including creative solutions specific to the needs and preferences of the consumer.

51. INDIVIDUAL ESTIMATED RESOURCES The IER will be a statistical calculation based on a correlation between the 63 questions on the needs assessment and historical costs of care for the individuals assessed. Needs assessment questions that have a statistically significant correlation with cost will be used to calculate individual IERs. IERs will be based on state wide data adjusted for cost of living differences.

52. The Individual Estimated Resources u The IER is an estimated funding amount intended to meet each person’s needs. u The funding amount is portable and moves with the person. u The IER is a threshold that will require review and approval for funding at levels above the IER. u Is intended to provide equity and consistency. u Is an important tool to better plan and budget for future needs.

53. The Individual Estimated Resources u People currently receiving services will have their funding level grandfathered so they will not experience any reduction in service. u The IER will be piloted in PFDS services. u The IER must be adequate to meet peoples needs who are enrolled in the HCBS Waiver. u The IER must be adequate to assure choice.

54. INDIVIDUAL ESTIMATED RESOURCES Each question in the needs assessment that is determined to be statistically significant in relation to historical costs will be assigned a specific dollar value determined by the correlation. ie Residentialyes$30,000 Medicationyes $5,000 Behavioralyes $10,000

55. INDIVIDUAL ESTIMATED RESOURCES IER = x 1 + x 2 + x 3 + x 4 + ……. X 64 IER = $450 + $3,000 + $32,000 ….. IER = $75,210

56. STATISTICAL & VALIDITY ISSUES u Normal statistical variation u Individual needs assessment’s validity u Model effectiveness impact u Direct care compensation impact u Variation in costs driven by model u ISP costs based on historical data u Reliability, validity and complexity issues around “total life” needs assessments u Provision for synergistic cost efficiencies u Correlation between need assessment & IER

57. Individualization IER RATES CHOICE ISP

58. “You'll be coughing up money for some time.” New Yorker Book of Doctor Cartoons

59. RESOURCE CONTROL POINTS u Consumer choice u Needs Assessment u IER u ISP Process u Service Coordinator u Fee Schedule u Legislative Allocation u IER Formula

60. “You don’t know how lucky you are! A quarter of an inch either way, and it would have been outside the area of reimbursable coverage!” New Yorker Book of Doctor Cartoons

61. “Competitive industry forceswill ultimately be as powerful as public policy forces.”

62. New Yorker Book of Doctor Cartoons

63. OPPORTUNITY u Choice & Self Determination u Individualized Budget u Invitation to qualify u More consistent policy u Secure Medicaid funding u Entitlement u Potential for full funding u Valid and reliable data u More equitable allocation of resources

64. “The ringing in your ears - I think I can help.” New Yorker Book of Doctor Cartoons

65. RESOURCES u Overview of the Transformation Process http://www.keystonehumanservices.org/transformationoverview.html u Links on human services, transformation, family resources and self determination. http://www.keystonehumanservices.org/links u Dauphin County Self Determination Web Site http://www.dauphinselfdetermination.org/ u Pennsylvania Office of Mental Retardation Web Site http://www.dpw.state.pa.us/omr/dpwmr.asp u Rate setting model http://www.keystonehumanservices.org/links#rate u This presentation http://www.keystonehumanservices.org/links#dctrans